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Influence of delay to diagnosis on prognostic indicators of screen-detected breast carcinoma

2002; Wiley; Volume: 95; Issue: 10 Linguagem: Inglês

10.1002/cncr.10961

1097-0142

Maurizio Montella, Anna Crispo, Giuseppe D’Aiuto,

Breast Cancer Treatment Studies

In their study,1 Olivotto et al. suggested that a delay in the diagnosis of asymptomatic breast carcinoma of 6–12 months is associated with disease progression as measured by an increased risk of lymph node metastases and larger tumor size. They also reported that the tendency to investigate women with a high suspicion for disease or a worse prognosis (suspicion bias) more expediently obscures the issue of whether delays of < 20 weeks also worsen prognostic indicators.1 Delay in the diagnosis of breast carcinoma causes anxiety for women and is a major source of malpractice litigation, whereas recall for uncertain results causes short-term distress and also may be the cause of an excess number of biopsies.2, 3 It therefore would be useful to minimize the number of women who are recalled. The influence of delay on tumor size in patients with breast carcinoma can be observed clearly in the results of many studies because the admission of women with large tumors greatly reduces survival rates.4, 5 This issue applies to both asymptomatic women in whom tumors are discovered at routine screening and women who present with symptoms (e.g., lump, tumefaction, pain, inflammation, etc). Diagnostic delay in symptomatic breast carcinoma patients has been demonstrated to be related to the level of education of the patients and residency in rural areas.6 Late diagnosis of breast carcinoma actually has been reported to be in decline as a result of improving socioeconomic conditions and ongoing prevention programs, but for women of lower income, lower education, and poor health care utilization habits, and those who generally are medically underserved, the problem of late diagnosis persists.7, 8 Over the last 10 years in Europe there has been an improvement in the early diagnosis of breast carcinoma thanks to “Europe against Cancer,” a European community program with the aim of reducing breast carcinoma mortality through health and prevention campaigns together with training programs for health operators.7 After introducing this program, the breast carcinoma mortality rate in England and Wales decreased by 21.3% between 1990 and 1998.9 Nevertheless, subjective variables such as patient age and level of education, physician specialization, and the practice of preventive mammography have been found to have more influence on the length of the diagnostic process and the delay is more evident in medically underserved women, who generally have a lower compliance rate in screening programs. To reduce the number of larger tumors in screening caused by a delay to diagnosis, educational training programs especially for medical underserved women should be developed. Moreover, in older women more attention should be given to education regarding prevention, whereas in younger women more attention should be given to addressing the psychologic aspects to reduce the suspicion bias and anxiety after an abnormal screen by biopsy.10, 11 The diagnostic delay (either in symptomatic or in asymptomatic patients) may be nothing other than the expression of complex and differing components linked to patient characteristics (e.g., premenopausal or postmenopausal), the tumor, the site of the lesion, the awareness and attention of the primary caregiver, screening compliance, the competence of the medical professionals involved in the treatment of the patient (e.g., radiologist, senologist, etc.), and (in a public hospital) the waiting list for admission to an oncologic institute. To minimize the influence of delay on prognostic indicators, a specific strategy and approach for women of different age groups, in different countries, and of different races is necessary. Maurizio Montella M.D.*, Anna Crispo Sc.D.*, Giuseppe D'Aiuto M.D. , * Unit of Epidemiology, National Cancer Institute of Naples, “G. Pascale” Foundation, Naples, Italy, Unit of Surgery “A”, National Cancer Institute of Naples, “G. Pascale” Foundation, Naples, Italy.